Policies and Laws for the Health of All

Contagious Conversations  /  Episode 26: Policies and Laws for the Health of All





Claire Stinson: Hello and welcome to Contagious Conversations. I'm your host, Claire Stinson. Every episode, we'll hear from inspiring leaders and innovators who make the world healthier and safer for us all. Contagious Conversations is brought to you by the CDC Foundation, an independent nonprofit that builds partnerships to help the Centers for Disease Control and Prevention save and improve more lives.

Joining me today is Sarah de Guia, chief executive officer of ChangeLab Solutions, a nonpartisan non-profit organization that uses the tools of law and policy to advance health equity. Sarah is committed to applying her legal expertise and leadership experience to advancing equitable laws and policies that ensure healthy communities for all.

Prior to joining ChangeLab Solutions, Sarah was director of government affairs and executive director at the California Pan-Ethnic Health Network or CPEHN, where her accomplishments included passage of more than a dozen legislative bills to further health equity and improvements in the quality of healthcare for immigrants, patients with limited English proficiency and communities of color.

In this episode, we discuss how to better engage communities to advance public health goals and policy development. We also explore how public health law can facilitate more systemic change within governmental public health to help address inequities. Welcome, Sarah.

Sarah de Guia: Thank you for having me.

Claire Stinson: We're excited for this conversation today. Let's talk a little bit about your background. You had an extensive legal background before coming to ChangeLab Solutions. We talked a little bit about your accomplishments in your introduction. Talk to us more about your background and why health equity is important to you.

Sarah de Guia: Sure. Well, Claire, my work on health equity is important to me because it's personal. My mom's family, my grandparents and my great grandparents were Mexican-American. And I would love to visit with them when I was growing up. We would travel to the Central Valley to visit them.

When my family was gathered, they would speak Spanish to each other and joke and share this bond through language. And I really wanted to learn Spanish as well. When I asked my mom when they were going to teach me Spanish, I was told that I shouldn't learn, because I could grow up with an accent.

I didn't really understand what that meant at the time, but it stuck with me. And it really bothered me. It was later in college that I began to understand my family's decision, because California was debating some very divisive ballot initiatives at the time. Efforts to ban affirmative action, to prohibit undocumented immigrants from accessing social services and healthcare and an attempt to roll back bilingual education.

At the time, I was a student at UC Berkeley. And I was studying ethnic studies, the history of racism and discrimination in the country. At the same time, I was out in the streets, protesting these laws that were trying to further institutionalize racism and discrimination.

It was through this experience and my studies that I began to make the connection between my family's decision or desire to hide their ancestry to the larger impact that laws and policies have on people and on communities. It was then that I began to see the power of law and policy. Unfortunately, from the negative side. I decided that I wanted to use those tools to be able to have a positive impact on people who have faced or could face discrimination. It was actually at the Mexican American Legal Defense and Educational Fund, MALDEF, which is where I worked before CPEHN. I had the chance to work on some groundbreaking legislation that would require healthcare plans and insurers to provide interpretation and translation services to non-English speakers.

So on a personal and professional level, it was going full circle for me to be able to protect individuals to be able to continue to speak their native language. Particularly, in healthcare settings. At CPEHN, I had the chance to further these types of policies in healthcare and making sure that communities of color, in particular, had access to healthcare.

But I also had the chance to work on public health issues. And it was there that I saw the intersection of racial justice and public health. Now, at ChangeLab, I'm able to work on those issues at a national scale. It's a really exciting time to be at ChangeLab Solutions.

As I reflect on this conversation and sharing my personal and professional journey, I wanted to share that while my great-grandparents and grandparents decided not to pass along their native language to myself or their other grandchildren, I did go on to learn Spanish. And I did have the chance to speak with them in Spanish before they passed. I think there was a tremendous sense of both pride and happiness from them, but also on my part. I share that because the work that we're doing in public health and health equity isn't going to have moments of instant satisfaction or instant gratification.

Our efforts today may not even be realized for generations to come, but we're going to have to work on it. And it's going to be painful and there's going to be moments of discomfort along the way. But for our future generations, we have to keep moving this work forward to build a healthier, more equitable world.

Claire Stinson: Wow, that's a really powerful story. And it sounds like your current job is the perfect intersection of all of these parts of your background. Let's talk a little bit about your current role ChangeLab Solutions. The organization is a nonpartisan, nonprofit organization that uses the tools of law and policy to advance health equity. Tell me more about your work at ChangeLab and what its mission means to you.

Sarah de Guia: I should start with the history of ChangeLab, because we were founded actually to help public health practitioners use the tools of law and policy to advance the public's health in new ways. The idea for ChangeLab came about when states were winning the lawsuits against tobacco companies. The Master Settlement Agreements.

Local health departments found themselves with these new resources to be able to go beyond traditional outreach and education efforts that public health tends to champion. ChangeLab was there to help these practitioners use legal and policy tools like land use and zoning regulations, the First Amendment and sales regulations to help address tobacco prevention from a systems and environmental approach.

That's exactly the way that I wanted to use law and policy, and here's an organization that's doing exactly that. From there, ChangeLab took what we were learning from those approaches into obesity prevention efforts. After many years, we were starting to see successes in these efforts.

At the same time, when we looked at the data, we saw a deepening of health disparities. Particularly, among low-income individuals and communities and BIPOC—Black, indigenous and people of color. We learned at that time that public health without equity will lead to disparities. And so, that's why today ChangeLab is focused on what we call the Five Fundamental Drivers of Health Inequity. We name these in our publication, A Blueprint for Changemakers.

Those five fundamental drivers include structural discrimination and racism ... income, inequality and poverty. Disparities in opportunity. Disparities in political power. Governance that limits meaningful participation. These five drivers shape everything around us. They shape where we live and how we experience life. The opportunities that we have. The power or the leverage of our voice.

The five drivers are also core to public health. If we look at the newly revamped Ten Essential Public Health Services Framework that was just released in September of 2020, we see that same focus on equity. The centering of equity in the activities and the goals to promote the public's health.

And so, right now, as public health practitioners ... and I'm excited to be at ChangeLab to do this ... we not only have the opportunity, but actually the imperative to focus on the five drivers. Law is a critical component to our success.

Claire Stinson: That sounds like a really important mission. Some folks listening to the podcast today may not understand the direct link between public health and law. Can you explain that a little bit?

Sarah de Guia: The main mission of public health law is to support the design, implementation, evaluation and ability to scale up measures that support public health and health systems. Our constitution, state and local laws and case law all support the role of government and its intervention to protect the public's health. This is because early studies of public health outbreaks and the spread of disease showed that when there's a shared understanding of the cause of the disease, coupled with the ability to take swift and broad action, we can better protect our health in a more effective and efficient way.

Some laws are express. Meaning that they're explicit in giving their power or authority to act. Some are implied, which means they're necessary to carry out those express powers. In general, state and local governments have the most power to pass laws to protect the public's health. But even the coordination and cooperation between levels of government is grounded in legal concepts.

You can see on a daily basis, public health practitioners are using law and legal concepts in many different aspects of their work. They're using these concepts when they develop food safety laws or housing enforcement codes and procedures, when they inform the public about certain risks and when they enforce compliance with codes and regulations.

A few years ago, to help inform and garner more support for law within public health, the Public Health Law Partnership, including ChangeLab, published an article to demonstrate why integrating law into the practices and activities of public health more broadly would yield better health outcomes. They created a framework that is meant as a companion to the Ten Essential Public Health Services.

And that shows again that when we ground public health in law, we can better ... one, define the problem to help us identify a solution that's effective and feasible. Two, identify a solution that's legally sound. Three, engage community to help build political will and have better informed policies. Four, have better and more equitable enforcement as well as better defend our legal solutions. And finally, evaluate the impact of laws and policies to see how they're working toward our broader health goals.

This framework illustrates how public health law isn't actually just one thing. But rather, it's drawing from multiple disciplines, like epidemiology, public policy, evaluation ... Even community organizing. But all centering law as an important foundation to aspects of public health more generally.

Claire Stinson: Thank you for explaining that. I think that's a really important point to make. The link between public health and law and policy is so important. Sarah, how can we better engage communities to advance these goals and policy development within public health?

Sarah de Guia: This is a question that is really important to me, as I spent a lot of my time and career working to engage communities in the policymaking process. At ChangeLab, we believe that the process of changing laws and policies to create healthy, equitable communities has to put the people who are affected the most at the center of those processes. Because again, if we take action without responding to or understanding what communities needs are ... again, they could have these unintended consequences and actually exacerbate health disparities.

As an example of this, just to make it a little bit more concrete, we had been working with a county to create anti-smoking laws or anti-smoking regulations in apartment complexes. The goal was to reduce the exposure to secondhand smoke amongst people who lived in those multi-unit housing. However, we found that the policy was being used to evict low income and BIPOC communities more often. Seemingly neutral laws can actually, again, have this negative effect on some groups or populations if we're not considering who's both benefiting from the law. As well as who could potentially be harmed.

Engaging community is really good policy, but it's also good for our health. Studies show that policy makers and community members both benefit when community is engaged in the policy-making process. That's because community members have ... it boosts their sense of self-determination. They understand what are the potential trade-offs in policy discussion. And then, on the government side, they have a much better understanding of how the policies will affect community members. Also, increasing local civic engagement just leads to better government accountability and transparency.

Claire Stinson: Thank you for explaining the importance of engaging these communities and the unintentional consequences of some of these policies. That's really important. What would you say is the biggest challenge to engaging communities?

Sarah de Guia: When we're thinking about engaging communities, we have to do so ... we have to take a couple of things in mind. The first is that relationships are built over time. And so, a key to success is trust with community. We can't skip over the process that we need to be able to get to know the community and to build relationships.

And so, I would say that is one of the key aspects. Sometimes the timeline for policies is short and the window of opportunity is really short, but it takes a long time for us to build relationships and trust with community. And so, that can be a challenge.

I think the second thing is that it's important to be intentional about the process. That's why I name public deliberation or community participatory budgeting as a way to think about the process differently. If we think about hearings that we might have attended in the past, it's often a one-way discussion. We're asking the community to give input, they give input, everybody goes home at the end of the day.

But that's not going to lead to intentional change. We have to really be intentional about the process. Be flexible with timelines. Make sure that we are being really thoughtful about how we're engaging community. Not just asking for feedback on decisions that we've already made, but actually really bringing them in as co-creators of those policies.

And then, just two last points ... It's important to build on community strengths and assets and let the community define the problem. But also, look to where are there opportunities and assets within the community that we can build upon. Not just framing it from a deficit model. And then, finally, community members need to be educated. Or they need some capacity building around governmental processes. Because it's not something that they do every day. But government also needs to learn how to work with community members and to be flexible and to speak plainly with folks. Because again, this isn't necessarily a part of their day-to-day. Both parties need a little bit of capacity building in order to have a really authentic and intentional engagement.

Claire Stinson: Thank you for explaining that. We keep coming back time, time again in this podcast to how important trust is with public health being successful. Thank you for sharing that.

Sarah de Guia: Absolutely.

Claire Stinson: Let's pivot to the Lights, Camera, Action National Summit Series. The CDC Foundation and our co-hosts are exploring ways to build a stronger, more equitable and more resilient public health system for the future in this series.

The most recent summit focused on strengthening public health law, governance and finance to support a modern system. Why do we need to strengthen public health law?

Sarah de Guia: I love this question, because it is at the core of our work at ChangeLab. And it's because we don't often as individuals think about the role that law plays in our daily lives. Yet laws have a profound impact on our lifetime trajectory. They determine where and how resources will be distributed, who's eligible for programs and services. They give government the permission to enforce protections and laws. And so ... actually, during the pandemic, we saw this in full force. How public health officials were able to respond because of the special powers that they have during emergency situations.

If I think about the number of laws that have had a positive impact on our lives, the Affordable Care Act comes to mind ... Medicare, Medicaid, the Civil Rights and Voting Rights Acts. These are really important laws that have an impact on our daily lives. Public health is right at the center of that, because public health isn't just one thing. It actually encompasses many different sectors and it touches many different aspects of people's lives. The food they eat, the air that we breathe, the water we drink, the environments in which we live. Public health plays a very important role in advancing laws and policies that help all of us be healthier people.

At the same time, law isn't perfect. In the United States, we have a long history of laws being used to exclude certain groups of people based on race or gender, sexual orientation, ability, or other kinds of sociodemographic status. And so, we have to keep this in mind. We have to remember the history of our laws and policies, in order to move forward to be able to improve public health.

Right now, we are seeing many localities, many local governments that are trying to address public health and equity through the passage of laws that at first glance may not seem like public health. But that again ... because public health is in everything that we do, they have the effect of improving our health. Such as minimum wage laws, access to affordable housing and even broadband access.

These are all things that we found during COVID-19 were foundational to our health. At the same time, there are some state governments that are using legal concepts, such as preemption, to thwart those efforts to improve equity. We need to actually strengthen public health lawyers, public health practitioners' understanding of laws, so that they have all of the tools that they need to advance equitable policy solutions.

I just want to name today that we are currently seeing about a thousand bills right now that are in circulation that would seek to roll back the authority of public health officials. That's the exact opposite of what we need to do right now. We need to be thinking about ... how can we improve our knowledge of law and policy? How can we make sure that public health officials have the tools that they need to use to be able to improve our health?

Claire Stinson: We'll be right back with Sarah de Guia.

The CDC Foundation is convening a National Summit Series on the future of public health in collaboration with the Association of State and Territorial Health Officials, the National Association of County and City Health Officials, Big City's Health Coalition and other public health partners to advance recommendations for a modernized U.S. public health system. The Lights, Camera, Action Summit Series includes four virtual convenings, leveraging recommendations across a variety of research. Learn more and register at futureofpublichealth.org.

Now, back to our conversation with Sarah de Guia.

The pandemic has certainly shown us the importance of public health. And it sounds like there's a real need to strengthen public health law. One of the topics highlighted during this summit was the importance of offering tools, strategy and information to policy makers and public health officials to strengthen public health. What are some of the public health law tools or resources that can help strengthen public health?

Sarah de Guia: Claire, it's a really exciting and opportune time right now for public health law. Because we, one, have momentum to really move forward strengthening public health law. One is that we have an increase in federal funding that is going to give local health departments an opportunity to invest, which have been chronically underfunded for years.

And so, right now, local health departments, they need this influx of dollars in the wake of COVID-19. Just to help them strengthen and build back and be able to, again, address the needs of their communities. Health departments can also play a role with these investment dollars to even support local community organizations that had been partners to them during the COVID-19, as we think about recovery as well.

I also want to name that there are many resources that are currently available to help increase the understanding and awareness of public health law. CDC has a Public Health Law Program. In combination with the Public Health Law Program at CDC, ChangeLab Solutions has created a Public Health Law Academy that's online. It offers essential trainings on public health law, as well as a legal certificate.

And it's free. It's open to anyone. We're even seeing professors use it in their classes right now. So there are some resources that are already developed and ready to go and are being used right now. We also need to make sure that we're thinking about training public health students and practitioners about how to engage in advocacy. Because right now, our voices in public health are needed.

And then, finally, I would say that there are a lot of collaborators out there who can help local health departments and others understand the role of law even better. The Center for Public Health Law Research at Temple University, the Network for Public Health Law, the Public Health Law Center and again, the CDC's Public Health Law Program all offer unique tools and resources to health departments that can better understand their capacity around law and legal concepts.

Claire Stinson: Really interesting points. Did you hear a lot of enthusiasm about some of these topics during the most recent Lights, Camera, Action Summit?

Sarah de Guia: I did. I had the chance to participate in the summit. There were so many wonderful ideas that came out of it, both important and urgent. A couple of the things that came out of that day was, one, just making sure that we are centering community engagement, and two, that we're addressing structural racism head-on in public health.

It's great to see the public health field and public health professionals naming that as a strategy and as a priority as we move forward. I would say part of the reason is because we can't have public health without equity. We need to make sure that we're centering equity in all of our public health goals. So that, again, we don't create policies and laws that are having those unintended consequences and furthering inequities.

Claire Stinson: Absolutely. How can public health law facilitate more systemic change within governmental public health to help address these inequities?

Sarah de Guia: Local and state health departments are central to systemic change. They create regulations. They distribute resources. They have the information and the data that is essential to the programs, the policies, the services that they're going to implement and roll out.

When equity is centered to that policy-making process, it will lead to better health outcomes for all. Even though not everyone may die from health disparities, everyone is ultimately affected by them. And so, having equity be at the center will help all of us improve our health.

Claire Stinson: Interesting. This conversation is certainly emphasizing the importance of public health law. Sarah, the concept of the common good has been challenged. What are your thoughts on restoring the spirit and value of the common good?

Sarah de Guia: This is a tough one. We do find ourselves in a time where there's tremendous political division and where public health itself has been polarized. But what the pandemic showed us is that we are all interconnected. My actions affect my entire community. They affect my family and my neighbors and the businesses. When we work together, we have a far greater chance of protecting ourselves and the greater communities that we live in. And I think to get us back to the spirit and value of the common good, we have to think about our values, the narratives that we use and the structures for engaging community and lifting up voices.

I just want to break those down. Communications research shows that even when we hold differing views on policies, we often share the same values for our families, our children and our communities. We value the belief that everyone should live in dignity and have access to safe and healthy opportunities. Appealing to those universal values that we all hold true could be a key to unlocking opportunities to build bridges across political lines.

Second, across all levels of government, staff and policy makers are our partners. They protect us and they create the infrastructure that will support our health and wellbeing. The primary role, in fact, of public health officials is to protect the health of community. It's time for us to uplift the benefits and protections that government offer us, because right now they're under attack for doing their job. We need to uplift and share the important role that they have played in health.

And then, finally, I would say the structures through which we see community engagement ... we need to do a little redesign on that. Because right now, they are most often benefiting the majority, the wealthy and those who have the loudest voices. But from our recent research that we did on how community organizations responded during COVID, we learned that partners have sage advice and knowledge about how programs and services are and are not working.

That needs to be captured in a more timely way and responded to in a more timely way. Our public engagement processes are not really accessible to people who don't speak English very well or people in rural communities that don't have access to stable broadband. Again, just rethinking how we are centering those individuals.

The last thing I would say is that community partners are really essential to health departments in how they are going to build trust with communities. And so, we need to, again, invest in those community partners and think of them as an extension of local infrastructure and government. Bring them into our processes for engaging the participation of communities who have long been excluded from participation.

Claire Stinson: Such important points right now. And I love the idea of really remembering that we need to listen to each other. I know that in another podcast episode, we talked about the need for deep listening right now.

Sarah de Guia: Yes.

Claire Stinson: And it sounds like that's at the core of what you're saying. Such an important conversation right now. Building on that ... How do we balance individual liberties with the approach of public health and its mandate of securing the common good?

Sarah de Guia: This is at the heart of public health law in general. If we look back to our constitution and the way that it was set up, and the fact that we have this constant balance of, "How do we make sure that individual liberties are valued and respected, but also respecting the common good?"

They go hand-in-hand. We are going to get things wrong at times. But ultimately, if we center those individuals and communities who are most vulnerable, who have historically faced the greatest disadvantage, disinvestment ... We will get to a place of being able to find that right balance. There's no magic bullet. There's no magic formula that we can follow. It has to be tested.

And I do think, to your point, we have to listen deeply to communities. All communities. Again, particularly those who have been most disadvantaged, in order to find that correct and right balance.

Claire Stinson: Thank you for sharing that. Your perspective on the path forward here is very important right now. Sarah, from a legal and funding perspective ... What do you see as the biggest challenge to strengthening the relationship between public health and health equity?

Sarah de Guia: Well, it's a really important question. Because I see the two as being very interconnected. As I've already said, we can't advance the mission of public health without equity. Right now, we have the funding from the federal government. There are dollars that are flowing. We're making investments in public health departments.

We have the frameworks and the data to show what's needed and to help us pave the way. There is a small window of opportunity right now to leverage this moment of awareness, acceptance, funding, and focus on public health and health equity. I would say the biggest challenge is we need to act and we need to act now.

Claire Stinson: Finally, I'll ask you a question that's more of a general question for today. What are your thoughts on the future of health equity in this country?

Sarah de Guia: I think we are making some important headway. I've been working in health equity for a couple of decades now. And I think the growth and the stretch and the momentum that I'm seeing is really positive. At the same time, there are some steps backwards. There's some new challenges and some new barriers that are being put into our way.

We work with very resilient communities. We work with very innovative communities. And so, we have to capture that innovation and that momentum to go forward. Because addressing the Five Drivers of Inequity in Public Health, it is complicated and it's complex.

We often talk about, "It's an iceberg." The little tip of it is pointing out above the water, but underneath there's a massive amount of complexity and of interconnected systems that we can't see underneath. And so, we have to really shine the light. We have to be patient with ourselves. We have to go deeper in order to really understand that. And it's not insurmountable. We can do this. I think public health law is an essential tool to help us get there. As well as thoughtful collaboration, increased knowledge of historical racial injustices. As well as being armed with the tools of law and policy.

We can succeed. Again, there's no time like the present. We have to use the momentum of COVID and the national uprisings to be able to commit. This really is our moment in public health to advance health equity.

Claire Stinson: It sounds like it is our moment. Thank you so much for being a part of Contagious Conversations. I hope we all shine the light on health equity and public health law in the future.

Sarah de Guia: Thank you for having me.

Claire Stinson: Thanks for listening to Contagious Conversations, produced by the CDC Foundation and available wherever you get your podcasts. Be sure to visit cdcfoundation.org/conversations for show notes. And if you like what you just heard, please pass it along to your colleagues and friends. Rate the show, leave a review, and tell others. It helps us get the word out.

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